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EAST 2016 Presidential Address

2016; Lippincott Williams & Wilkins; Volume: 81; Issue: 1 Linguagem: Inglês

10.1097/ta.0000000000001095

2163-0763

Stanley Kurek,

Cardiac, Anesthesia and Surgical Outcomes

Stanley J. Kurek, Jr., DO, EAST 2016 PresidentI am truly honored and humbled to serve as the 29th president of Eastern Association for the Surgery of Trauma. It’s not without the help of so many people, many of whom I am pleased to say are here in the audience this morning. It’s impractical to mention everybody that has helped me along these 15 years because so many have touched my life in such a positive way and helped me to reach my dream of being the president of this great organization. I would be remiss by not starting with my biggest fans and supporters, my family. First, my mother, Betty—a registered nurse and nurse instructor—and her husband, Stan. If it wasn’t for my mother’s love of medicine and her endless dedication to helping patients, both young and old, I would have never been exposed to the world of medicine. Growing up in a small town, and having the opportunity to visit her at the hospital and see all the people she touched and helped, was such a positive influence in my life, so thanks Mom. Also here today is my youngest brother, Nate, and his wife, Christine. He’s always been a big supporter, and I’m so glad he could make it. My other brothers had to work, and so they were not able to be here, but we’ll show them the video. No one has supported me more than my best friend and wife, Teri. She maintains the sanity in our lives during all of the ups and downs. We have certainly beaten the odds by having celebrated our 25th wedding anniversary last June. She has been my rock since marrying me while I was in medical school at the Philadelphia College of Osteopathic Medicine. After graduation, she then stuck with me for 6 long years in Johnstown, Pennsylvania, as I completed my general surgery residency. It’s a great place to learn medicine, but it’s kind of a tough place to live. We then had several fun years with the infamous Drs. Pasquale and Cipolle at Lehigh Valley Hospital and Health Network. Even after several more moves and changes, she has been my soul mate and keeps an important balance in my life. She’s an awesome educator, mother, friend, and overall great person. As you all know, in January 2006, our life was changed forever when we were blessed with the miracle of two healthy EAST kids. Like Nicole said, that was the only annual scientific assembly I ever missed. These two blessings have made our lives complete, and I am so proud of their accomplishments already, and they’re only 9 years old. Being a father has changed me in unimaginable ways. Cooper, is my thinker, my reader, and my eater, and he is always so inquisitive. Unfortunately, he still loves the Gators, and we are still huge University of Tennessee fans, and so we do have a house divided. Callista, my beautiful little girl, is also quite bright, and she has a knack for the arts, dancing, ballet, and music. I had to put a picture of our dog in the presentation, or she was going to be mad at me this morning. I hope to see her make it someday in Nashville. She loves country music, and she is already writing songs. If she doesn’t make it there, she wants to be a veterinarian. So I support and wish both of my children the best of luck in their ventures in life. I have to thank many of my mentors and friends from my earlier years as well. Drs. Moore and Hughes from my residency years and many positive influences from Lehigh Valley are pictured in this presentation. So many close friendships were made and still exist today. They have all made me what I am today as a surgeon. I have to thank my more current mentors and friends, Blaine Enderson, Fred Luchette, Dr. Jim Hurst, Michelle Ziglar, and Kimbal Maull, who has always been a supporter and advisor. As Nicole mentioned, I kind of took the remedial path to presidency. I have the greatest respect, admiration, and appreciation for the EAST presidents I served under in various roles over the past few years, and I can’t say enough about the board of directors that I have worked with, especially this past year. The talent is just unbelievable. They are all leaders in trauma care, and I can’t thank them enough. They are total stars. Thank you all for your hard work this past year in making this a great meeting. Also, I can’t thank this next bunch of women enough—Christine Eme, Rachel Dixon, and the entire EAST office staff. Their support for our organization is amazing. They are so dedicated, always hardworking, and always able to improvise when things need to be fixed. What a wonderful staff. I certainly miss Christine this week as many of you do as well. Resilience, why this topic? It seems that you hear this word bounced around a lot these days and for good reason. It’s an excellent concept for thinking about how people, systems, and organizations respond to change. It’s a characteristic that I believe every trauma surgeon needs to possess to be successful in doing what is best for their patients. It’s something you have to possess when you work 30 hours, and you’re ready to go out the door of the hospital and another problem arises. It’s something you have to possess when somebody doesn’t think you’re a good fit for their department because you’re too much of a family man or you have envious partners. These examples can go on and on and on in today’s world. Simply put in the physical sciences, resilience is the ability of objects to resume their original shape after being stretched or bent. In people, it’s the ability to bounce back after a change or adversity in their life. This is a little misguided though, because there is no back to bounce to since time moves ahead. It is more accurate to think of resilience as the ability to bounce forward.1 It means facing life’s difficulties with courage and patience and refusing to give up. Resilience is rooted in the tenacity of spirit and the determination to embrace all that makes life worth living, even in the face of overwhelming odds. When we have a clear sense of identity and purpose, we are more resilient, because we can hold fast to our vision of a better future. Much of resilience comes from community, from the relationships that allow us to lean on each other for support when we need it. The concept of resilience first showed up in the corporate lexicon in the late 1990s with the release of Paul G. Stotlz’s book titled Adversity Quotient: Turning Obstacles Into Opportunities.2 He theorized then that an organization’s or a person’s success in the world is based largely on the ability to cope with adversity. According to his research, people with a high adversity quotient make more money, are more innovative, and are better problem solvers than those who are less adept at handling misfortune. Unsurprisingly, though, if you ask five different people what resilience is, you will get five different answers. Social scientists have long been intrigued by what enables some organizations and people to thrive in the face of adversity, while others buckle under the pressure. So does resilience really matter in medicine and trauma surgery? Diane Couto writes that “…more than education, more than experience, more than training, a person’s level of resilience will determine who succeeds and who fails. It’s true in the cancer ward, it’s true in the Olympics, and it’s true in the board room.”3 In almost all the theories out there, resilience overlaps in three key ways. Resilient people possess all three of these characteristics: a staunch acceptance of reality; a deep belief, often buttressed by strongly held values that life is really meaningful; and an uncanny ability to improvise. “You can certainly bounce back from a hardship with just one or two of these qualities, but to be truly resilient, you need all three.”3 Resilience is great if you’re getting punched in the face, but it does nothing about the fact that you’re actually getting punched in the face. So how do we become more resilient? How do surgeons like Trunkey, Feliciano, Rozycki, Rotondo, Schwab, Peitzman, Pasquale, and many others stay active and continue to make a difference in our world? The changes and career challenges they have faced are likely innumerable, but they continue to move ahead. The personal journey through change is depicted in Figure 1.4 When you experience an abrupt change, one usually goes into denial. Depending on your level of resilience, you may stay in this state for a while. You then move into a level of resistance for a period of time, but with resiliency you begin to explore new venues, become committed to a new task, and then transition into a new beginning.Figure 1: Transition curve: personal journey through change. © 2013 Teresa Moore, MS, NCC. Reprinted with permission.Writer Eric Barker notes that the following eight steps are ways to make yourself more resilient when life gets hard. They are acceptance of change; perceive and believe; manage your emotions; self-empowerment; prepare; stay busy, busy, busy; professional networks; and reflect and give help.5 Acceptance of Change The first thing we need to do when we’re facing difficulty is to make sure that we recognize it as soon as possible. It sounds pretty obvious, but we all have been in denial at some point in our lives, but we need to accept the change. So how do people who survive difficult situations persevere? They move through the grief, from denial to acceptance faster. Manage Your Emotions It seems pretty straightforward, but do you know that there have actually been scuba divers who have died with plenty of oxygen still in their tanks? You ask yourself, how is this possible? Well, divers have panicked and pulled off their regulators to get the obstruction out of their mouth and subsequently drowned. I am certainly preaching to the choir—most of you in the audience are trauma surgeons because you have a calm demeanor and can multitask very well. I think it’s an integral part of being a good trauma surgeon, although I know a few who jump off the handle pretty quickly. Earlier in my career, in the Pasquale/Cipolle years, I was like that as well on occasion. I wouldn’t say a hot head, but always very passionate when it came to quality trauma care. But, as confidence grows and you start to believe in yourself, you learn that most things in life are not worth getting that upset over. Oscar Guillamondegui gave a great presentation at the Leadership Workshop, and it was nice to hear how he has learned to adapt and stay calm and has learned how to control his emotions throughout his career. He actually talked about one of the ways he does it, prayer. Prayer is a powerful exercise. I pray frequently myself, and I pray for patience, allowing me to strengthen my sense of resiliency. Dr. Pasquale taught me something a long time ago, soon after finishing my fellowship. It has stayed with me ever since, and I continue to preach this to my younger attending physicians, residents, and fellows. If you ever get upset about something, don’t jump too quickly to respond. You have to stay calm, go home, and think about it for about 24 hours before you send off that emotionally driven email. It’s so easy to fire off an angry email, and once it’s gone, it’s gone, and you can’t get it back. That one thing has kept me out of trouble many times, and it works. Just calm down for 24 hours and think about it and then follow up the next day. Thank you again, Mike. Self-Empowerment Self-empowerment, in its simplest form, means taking charge of your own life, in your workplace, with your colleagues, with residents, medical students who look up to you, with your superiors, with your body, with your illness if you’re unfortunate enough to have one, and in caring for yourself. Again, this sounds pretty obvious, but how come most of us don’t do it? The reason for this is that we don’t all have a full understanding of how to do it properly, or even what it means. We seem to rely on some sort of gut instinct or a thought pattern within us, in which we think that this is the way it should be done. You have to have a strong internal belief system and not blame others for your mistakes. One of my attending physicians who just happens to be here today had a great quote that my children are sick of hearing me say, and that quote is “Excuses are the poetry of failure,” and if you think about it, it’s a true literal statement. I think there are some fourth-graders probably in south Florida who have heard that from my own kids already. Self-empowerment is a behavior one must possess to build resiliency Prepare After living in south Florida for 4 years, I can now say I firmly believe that there is no such thing as a “pretty good” alligator wrestler. My children and I love Paul from the show Gator Boys. After a visit to the Gator Ranch to see him, it’s apparent that master alligator wrestlers are well prepared. Who survives threatening situations like trying to catch a gator or swimming from a gator? Really, it’s the people who have done it before, people who have been prepared. It’s tough to prepare, though, for a situation that has not happened yet, but one way you can make yourself better is to have productive habits and eliminate wasteful ones. I might have done a case a thousand times, but I will still pull out a textbook and review the case and the key elements to make sure I’m fully prepared. Over the last 4 years, I’ve had a very close relationship with my chief executive officer, my chief financial officer, and my chief nursing officer at Lawnwood Regional Medical Center. Through these individuals, I have learned a lot about the business of medicine, but I am certainly no expert. One thing that I have learned, though, is that if you don’t come prepared, or if you arrive late, you might as well just go back to bed, because they are going to chew you up in that boardroom. One of the easiest ways I have always felt to even a battlefield is to be prepared. Preparedness helps develop resiliency. Staying Busy and Working, Working, Working Richard Mollica is a Harvard psychiatrist who has done a lot of work with trauma patients. He states that the single most important goal of recovery from a traumatic event is to stay busy.5 “The hands force order in the mind,” an author wrote, summarizing Mollica’s work.6 Resilient people know that staying busy not only gets you closer to your goals, but it also is the best way to stay calm. Dr. Scalea, in last year’s AAST presidential address, touched on how important relationships are in our trauma community, and he also talked about the work-life balance.7 Everyone here has to figure that part of the puzzle out for themselves, but I truly believe the shift-worker trauma surgeon mentality seen nowadays at some trauma centers is doing a disservice to our profession and to our patients. We have to find a balance between taking care of ourselves, our careers, and our families. This balance aids in producing resiliency. Professional Networks I still remember one of my chief residents many moons ago who would say, “Don’t feel bad about calling me, but don’t forget that it’s a sign of weakness.” He put the fear of God in a lot of our younger residents for years, but resilient people know when to call for help and know when to get others involved. Our trauma world, as you know, is such a small world, and if you reach out to a friend or call an old mentor, they have probably experienced the same problem at some point in their career that you’re dealing with right now. I have said this a thousand times, but one of the most important qualities of this organization is networking and befriending others. I think it’s such a key component of what makes EAST so special. There is no better place to be than here in a room like this today with people who have the same passion as you do. These colleagues provide the support needed to maintain resilience in this ever-changing and challenging life of trauma. Reflect and Give Help Years ago, we all chose to dedicate ourselves to helping others. Giving help in times of our own personal stress, even in the worst of times, can certainly help you. There aren’t many professions out there that are as powerful as ours as caregivers. Society has given us the power to touch so many lives on such an intimate level. I constantly remind myself that the patient always comes first. Listen to the patient; be caring and thoughtful of what they are experiencing, and spend time with them and their families. A recent study published not too long ago showed that just simply reaching out and shaking a patient’s hand or just laying your hand on their shoulder when you are talking actually makes a huge difference in their recovery.8 I have seen surgeons disconnect from this important part of being a good doctor. It’s easy to use a medical student or physician’s assistant as a buffer between you and the patient. This power of aiding others and reflecting on someone else’s needs is an important resiliency tool to embrace as surgeons. I am going to tell a quick story about how I went outside my comfort zone once as a junior attending physician. I had a patient, Bernie, while I was at Lehigh Valley Hospital. He was a truck driver, and one day at work, he took his 18-wheeler off the on-ramp of the interstate, flipping over the truck. It actually landed upside down, and when it landed, he had the gear shift impaled right up through his rectum. He came in as a trauma alert with an open-book pelvis fracture and obvious rectal injuries and some bowel injury as well and spent probably about 2 or 3 months in the hospital. He had an open tib-fib fracture, some other orthopedic injuries in addition to his open-book pelvis fractures. He underwent an emergent damage control laparotomy upon presentation to the hospital. After several abdominal procedures, his abdomen was closed, his pelvic fractures stabilized, and he was transferred to inpatient rehabilitation. After being discharged from rehabilitation, I saw him back in clinic to discuss a colostomy reversal. Bernie is such a great guy with an incredibly supportive wife. I remember her actually passing out in the surgery waiting room the first time I met her to give her the news of Bernie’s condition. Bernie fits the typical stereotype of a hard-nosed biker with long hair, multiple tattoos, and a tough demeanor. Not a typical guy who would reach out to befriend me. Bernie and I, though, got to know each other very well over a few-year period having his colostomy reversed, subsequent hernia, and hernia repair. After almost making a full recovery, I unexpectedly received an invitation to come to his “life party” that his family was throwing for him. When I received the invitation, I didn’t know what to do. I never did that before. Get that close with a patient? As trauma surgeons, we take care of a lot of individuals that you probably would not want to meet in public. You know our patient population. So we really contemplated attending and decided to go. The party was set up at a rural park outside Allentown and was decorated beautifully for Bernie’s first “life party.” What I didn’t know was that the party was for me as well, because I had “helped” save his life. His family and friends were so appreciative. I don’t think I ever had so many people thank me for just doing my job, and I certainly have never received as many presents from strangers than I did that day. They made us feel so welcome and were so thankful. That party was 13 years ago, and I am still amazed that he sends me birthday cards every year and is still so appreciative. I would have never gotten to make such a good friend and meet so many great people if I had stayed only in my comfort zone. So once the threat has passed and the dust has settled, how can we go back to a normal life again? Actually, sometimes life can even be better after a big change. To live full lives, some amount of difficulty is essential. You can meet life’s challenges with resilience, competence, and grace. I know you’ve all heard this phrase before, but it’s certainly apropos here: “What does not kill you in fact will make you stronger.” It’s time to change gears a little to discuss EAST’s resilience. It’s truly amazing how far we have come since the first meeting of four great minds, Drs. Jacobs, Harris, Maull, and Champion on July 17, 1986. They helped to organize and start this organization, and we’ve grown from a tiny group to more than 2,000 members this year. Dr. Sagraves spoke of staying relevant, and I call out to each and every one of you here today to help this organization to stay strong and hold onto the vision of our founding members.9 If we lose that vision, we’ll become like every other big organization. This organization, under the leadership of Dr. Rotondo during his presidential year, redefined in a very clear fashion our mission, vision, and strategic goals. Adding these key elements truly gave our organization a clear path into the future. Ben Franklin once wrote that when you’re finished changing, you’re finished. EAST had certainly evolved and has grown since that retreat. Some of these efforts started since have included increased efforts for fellow recruitment into our organization, reaching out to the advanced practitioners, and helping the Pediatric Trauma Society form and then go on to what it is today. Our mentoring program and online education initiatives are outstanding. I am extremely proud about starting the Leadership Workshop after being directed by Dr. Rotondo to do so in 2006. It’s been one of the most well-attended workshops since its inception, and I have learned something every year that I have attended. We now have two recent online townhalls and multiple traumacasts and careercasts that are all incredible and have educated many throughout the country. As you all are aware, with the restructuring of the EAST Board of Directors that was initiated by Dr. Sagraves and finalized under Dr. Davis' tenure as president, it has helped this organization maintain relevance to all of our members. I ask you, though, is that enough? Are we reaching out effectively to recruit surgical residents to specialize in acute care surgery? Are we reaching out effectively to our fellows to join EAST and get involved with our great organization early in their career? With the help of Cindy Talley, our Career Development Section chair, and Kim Hendershot, section member, we sent out a survey to surgeons either finishing their fellowship or who have completed a fellowship within the last 5 years. I am excited to share these results with you. This was sent out to approximately 215 surgeons, with a response rate somewhere around 40%. Seventy-three percent of responders completed their training within the last 5 years, while 27% are now current fellows. The majority practice in a mixed acute care surgery model covering trauma, critical care, and emergency general surgery. Surprisingly, only 13% are doing elective general surgery. Seventy-eight percent are planning on staying at their present institution, while 22% may relocate within 5 years. The next question related to the amount of exposure they had received during their fellowship on the following topics: clinical decision making regarding trauma, acute care surgery and surgical critical care; trauma operative skills, acute care surgery operative skills; their exposure to learning about trauma systems and injury prevention; how much exposure they had regarding basic and advanced research; exposure to topics including starting or joining a practice, making money, contract negotiations, and hospital politics. We then asked them to rate how much exposure they received: none, very limited, limited, sufficient, and extensive. Clinical decision making in surgical critical care and in trauma had the highest response rates of extensive exposure, while clinical decision making in acute care surgery was split between extensive and sufficient exposure. The following areas were fairly evenly split between sufficient and limited exposure: operative skills in trauma, and acute care surgery, trauma systems, injury prevention, and basic trauma research. The areas that the responders felt they had limited to no exposure were advanced research, starting or joining a practice, making money, contract negotiations, hospital politics, and dealing with administration (Table 1).Table 1: How Much Training Did You Receive in Your Fellowship in the Following Areas?The next survey question was: How important do you think these same areas are in relation to being a trauma and acute care surgeon? The top three extremely important areas chosen were clinical decision making in surgical critical care, trauma, and acute care surgery. Operative skills for trauma and acute care surgery were extremely important as well. Surprisingly, the remaining areas were scored somewhat important to important. Ninety-four percent felt that they were adequately prepared to become a trauma and acute care surgeon. Next, we wanted to see what the most important aspects were when searching for a job, and I think the responses are surprising: The most important factor was actually location, followed by level of trauma center, and having teaching opportunities. Call structure, having a mentor, academic opportunities, and salary were less important. However, when asked what were the top reasons you chose your current position, location was no. 1, followed by having a mentor, and finally the level of trauma center verification (Fig. 2).Figure 2: Top three reasons respondents chose their current job.We then asked them what was enjoyable about the interview process. Sevently-three percent responded meeting all of the faculty, 45% said they enjoyed the dinner or lunch; 40% enjoyed the tour; 30% enjoyed learning about the job requirements; and my favorite is that 9% said that there was nothing enjoyable about the process. The next question asked was: Did anything detract from the experience? Eighty percent said no, but 10% said that meeting hospital administration was a detractor, and 10% thought discussion of salary and benefits was as well. The mission statement of EAST is that we are a scientific organization providing leadership and development for young surgeons active in the care of the injured patient through interdisciplinary collaboration, scholarship, and fellowship. The next question presented was: Do you feel that EAST fulfills its mission with the opportunities, activities, products, and services that it provides? Sixty-three percent said yes, 16% said somewhat, and 22%, unfortunately, did not know enough about EAST to answer that question. Luckily, no one said no. The final survey question asked the responders to rank the importance of several factors in relation to what a trauma organization provides to you as a recent fellow or a recent graduate. The “extremely important” offerings were clinical decision-making guidelines, keeping current with the literature, and networking and support. Offerings that were “important” were CME opportunities, exposure to participate in research studies, mentoring, advocacy, family-friendly educational conferences, awareness of job opportunities, and learning about contract negotiations. My overall impressions about this survey are that the responders believe that they received a good amount of teaching in all areas of clinical decision making during their fellowship. However, our fellowships are falling short in teaching advanced research and in the following career development areas: joining a practice or starting a practice, contract negotiations, making money, dealing with hospital politics, and dealing with administration. Thirty-six percent of our fellows and new surgical attending physicians don’t belong to a national trauma organization, and I believe they’re missing out on one of the most rewarding aspects of a surgeon’s career. I call on everyone here today to devise new ways to try to entice young surgeons to join our organization (Fig. 3). Our flagship offerings—practice management guidelines, literature reviews, CME and research, the ability to volunteer, and our mentorship programs—are so vital to the young surgeon. Disturbingly, only 63% believe we are achieving our mission, and so that leaves a lot of people out there who believe we don’t. So I call on everyone again, as members of this organization, to develop and initiate new ways to capture the essence of our mission.Figure 3: Trauma organization memberships.We need to continue offering career development workshops like we’ve put on earlier this week. The Leadership Workshop was, once again, well attended with 36 attendees and, as always, had timely and relevant presentations. I am so excited to announce that we held our very first fellow-specific workshop titled “Bridging the Gap.” This workshop was set up by Kim Hendershot, Shea Gregg, Dave Skarupa, and several others from the Career Development Section. There were 29 workshop attendees with topics ranging from academic versus non-university jobs, how to ask the right questions and be a great applicant, and how to stay out of trouble. Topics also discussed were help with contracts, how to find your focus, and ways to develop your portfolio. Those are all topics I personally needed guidance with early on in my own career. People have asked me to state what I would proclaim to be my legacy in this great organization, and I have to respond that it is the development of these two great workshops aimed at our target audience, the young trauma surgeon. So is EAST a resilient organization? There are, again, many models that define organizational resilience. Common indicators are that resilience is based on effective leadership, a shared vision of organizational values, and a systematic capture of critical information to keep the organization running smoothly. Also required are updated policies and procedures to meet changing demands, a can-do culture, a motivated staff, and members who are deeply connected to its sense of purpose. After reviewing these qualities, I believe we as an organization are strong. I have met the most influential and the most special people I have ever known because of this organization. Our current leaders are dedicated as ever. Even though we have grown larger, we are committed to the passion and the vision of our founding members. This is my last challenge as president to all of the great minds that are a part of EAST today. I don’t know if all of you realize that we’ve had a lot of sessions and talks this week that dealt with something a lot different than trauma or emergency general surgery. Many talks focused on human behavior and how to better oneself, this address hopefully being one of them. In addition, we’ve had topics including, but not limited to, Who Are You: Social, Emotional, Intelligence Motivations; Understanding Your Strengths, Weaknesses, Skills, and Abilities; How to Stay out of Your Chair’s Office; Finding Your Focus; and Mentoring Relationships. Are we all getting soft as trauma surgeons, or are we all becoming more human and less of a superhero? Dr. Malangoni’s Frame Lecture discussed self-confidence, competence, and judgment and gave us several challenges as well. How do we continue to expose students to surgery earlier and be good surgical role models? Second, how do we increase the efficiency of the educational process? Third, how do we teach teachers how to teach? Fourth, how do we become good role models? I hope that my discussion about resilience will help those who face challenging situations or abrupt changes in their lives. Unfortunately, we are not born with this virtue, and you can only become more resilient with change. I am so proud to be the first osteopathic surgeon to serve as your President, and I could share many stories about challenges and changes that I have faced in my own short surgical career to date, but honestly, it is my personal journey through change, and I pride myself on my own ability to be resilient. I would like to close today by again thanking my family for their love and support and also thanking everyone who has helped make this organization a huge success. I have to thank the board of directors and the executive committee that have worked so hard and are simply just phenomenal people. The EAST office staff, they are the most efficient, dedicated, and brightest people I have ever worked with, and finally, I would like to thank all of you, the members of EAST, for giving me the opportunity to serve as your president this year. I am confident that EAST will continue to grow and be innovative under the able leadership of my successor, Nicole Stassen. With great appreciation, thank you EAST. DISCLOSURE The author declares no conflict of interest.